BEIRUT: Although humanitarian aid programs are designed to offer relief to vulnerable communities, unsustainable projects and problematic exit strategies can end up having adverse effects on their recipients. In 2010, the Lebanon branch of Medecins sans Frontieres (Doctors Without Borders) implemented a mental health program in the Palestinian refugee camp of Burj al-Barajneh, in south Beirut. Three years later, the services it provided were concluded with a rocky handover process – in some instances leaving beneficiaries desolate.
The case of this program was documented and studied by MSF employees and several professors at the American University of Beirut, who authored an article titled “Evaluating a Mental Health Program for Palestinian Refugees in Lebanon.” Published in the Journal of Immigrant and Minority Health in September, the article highlights the ethical dilemmas bound up in the program’s disorganized termination.
“Lack of planning for sustainability and proper procedures for the handover of the program constituted a major downfall,” the article concluded. “Program discontinuation posed ethical dilemmas, common in provisional interventions in underprivileged refugee communities.”
MSF’s program offered psychiatric services, providing psychotropic drugs to patients as well as a variety of counseling options at no charge. The center’s advocacy work to destigmatize mental health care, as well as its accessibility, proved to be a success. Patient enrollment increased throughout the three years it was running.
By 2013, the program’s mandate had concluded, just as the Syrian refugee crisis was becoming critical.
MSF priorities had shifted and the Burj al-Barajneh team began packing their bags.
The long-standing plan for the closure of the program entailed handing over the provision of mental health services to the United Nations agency for Palestinian refugees (UNRWA) and the local Burj al-Barajneh municipality. In practice, the scope of this transfer of responsibility proved to be more complex than anticipated.
“The exit strategy for the project and handover was planned on day one, but, as in all our projects, there are always challenges to execute handovers the way MSF wanted,” Zeina Ghantous, co-author of the article and deputy head of mission at MSF, told The Daily Star.
“You can’t always find the actors ready to deliver your services in the same capacity you [could]. The main challenge is not only to continue the quality of services but to ... deliver those services free of charge.”
Following MSF’s official exit, the team stayed on-site for six months to support UNRWA and the local municipality by training psychologists, hiring employees and providing medication. Still, their study found an immediate drop in beneficiary satisfaction.
“The most challenging aspect for the patients was continuity in getting the drugs,” Dr. Nasser Yassin, another co-author, and director of research at AUB’s Issam Fares Institute for Public Policy, told The Daily Star. “It’s not cheap, medication, and can be largely unaffordable for members of the community.”
For patients diagnosed with depression or anxiety, commonly prescribed treatment includes selective serotonin reuptake inhibitors. A sudden halt in this medication commonly leads to severe withdrawal.
While funding was prioritized for those with more severe mental health issues, MSF’s designation of services to both UNRWA- and municipality-funded health centers proved confusing to some patients who were unaware of their options.
“We had informed them months before leaving and told them of who would be taking over. It seems, though, that some patients did not really receive all of the information,” Ghantous said.
The study examining the project was welcomed by MSF, who used the results to reimagine its exit strategies. Just over a year ago, a new mental health care program was opened, albeit with slightly different goals.
“We do counseling, mostly looking at short-term, solution-focused therapy, where we assist our patients with tools and strategies for them to cope better in their lives,” Helena Jonsdotti, mental health activity manager for MSF Lebanon, told The Daily Star. “We’re no longer running a psychiatric program.”
The current program is scaled-down somewhat from its predecessor, according to Jonsdotti, with less focus on advocacy.
While the study was focused on only one MSF program, Yassin noted the importance of understanding its implications for all ongoing aid projects. “As much as initiatives by non-governmental and international actors are well-designed, there are potential issues that could harm the users and beneficiaries,” Yassin said.
“Pragmatically ... they move on to other vulnerable groups as they’re always looking to aid the most vulnerable. Also, with time, you begin to see donor and aid fatigue. Money begins to dry up, and without proper sustainability mechanisms, there is a potential backfire.”
For Yassin, the results of the study should be particularly pertinent to organizations tackling aspects of the Syrian refugee crisis. UNHCR, the United Nations refugees agency, has increasingly appealed for additional funding in the past few years, but its requests have yet to be fulfilled. As of September 2017, UNHCR’s required budget stood at $7.7 billion, but the available funds had dropped to $4.2 billion – about 46 percent short.
“The issue of Syrian refugees is much more problematic and concerning because of the growing tensions between refugees and host communities,” Yassin said. “Considering the volume of refugees living in poorer areas, much aid goes toward benefitting the entire community – but there are real concerns as to what might happen if the aid dries up.”
“We need to be strategic and really care about all beneficiaries,” he concluded.